Get Request An Appeal

Submitting a REQUEST AN APPEAL is an important step when you wish to contest a decision regarding your eligibility for health benefits. This guide will provide clear and concise steps to help you successfully complete the online form.

Follow the steps to complete your REQUEST AN APPEAL form

1. Press the ‘Get Form’ button to access the REQUEST AN APPEAL online form and open it in your preferred editing tool.
2. Enter today's date in the provided field. This is the date you are submitting your appeal.
3. Fill in the date shown on your notice of eligibility. This helps to establish the timeline for your appeal.
4. Provide your personal information in the APPELLANT INFORMATION section, including your last name, first name, middle initial, birthdate, and Social Security number. Indicate if your name is your legal name.
5. Include your street address, city, zip code, and any alternate phone numbers where you can be reached. Select your preferred contact method by checking the appropriate box.
6. If your health coverage is through an employer, provide the employer's name and phone number.
7. In the REASON FOR YOUR APPEAL section, check all that apply to your situation. If additional explanation is necessary, provide details in the space provided.
8. Indicate if you require a language interpreter or any accommodations, and specify what you need.
9. If you are a member of a federally recognized tribe, check 'Yes' and specify your tribe.
10. If you have a representative acting on your behalf, complete their information, including their name, relationship to you, and contact information.
11. Sign and date the form where indicated to attest that the information provided is accurate to the best of your knowledge.
12. Once all sections are completed, save your changes. You may choose to download, print, or share the form as needed.

Begin your appeal process by completing the REQUEST AN APPEAL online today.